BACKGROUND Despite numerous advances in resuscitation care in recent years, it remains unknown whether survival and neurological function after in-hospital cardiac arrest has improved over time. METHODS We identified all adults with an index in-hospital cardiac arrest at 374 hospitals in the Get With The Guidelines-Resuscitation registry between 2000 and 2009. Using multivariable regression, we examined temporal trends in risk-adjusted rates of survival to discharge. Additional analyses explored whether trends: (1) were due to improved survival during the acute resuscitation or post-resuscitation care and (2) occurred at the expense of greater neurological disability among survivors. RESULTS Among 84,625 hospitalized patients with cardiac arrest, 67,135 (79.3%) had an initial rhythm of asystole or pulseless electrical activity while 17,490 (20.7%) had ventricular fibrillation or pulseless ventricular tachycardia. The proportion of cardiac arrests due to asystole or pulseless electrical activity increased over time (P for trend <0.001). Risk-adjusted rates of survival to discharge in the overall cohort increased from 13.7% in 2000 to 22.4% in 2009 (adjusted rate-ratio per 1-year: 1.04, 95% CI [1.02–1.05]; P for trend <0.001). Survival improvement was similar in both rhythm groups and largely due to improved survival from the acute resuscitation (risk-adjusted rates: 42.7% in 2000, 54.1% in 2009; adjusted rate-ratio per 1-year: 1.03, 95% CI [1.02–1.04]; P for trend <0.001). Importantly, rates of neurological disability among survivors decreased over time (risk-adjusted rates: 32.9% in 2000, 28.1% in 2009; P for trend=0.02). CONCLUSIONS Both survival and neurological outcomes after in-hospital cardiac arrest have improved over the past decade.

Importance Publicly available datasets hold much potential, but their unique design may require specific analytic approaches. Objective To determine adherence to appropriate research practices for a frequently used large public database, the National Inpatient Sample (NIS) of the Agency for Healthcare Research and Quality (AHRQ). Design, Setting and Participants In this observational study, of the 1082 studies published using the NIS from January 2015 – December 2016, a representative sample of 120 studies was systematically evaluated for adherence to practices required by AHRQ for design and conduct of research using the NIS. Exposure None Main Outcomes All studies were evaluated on 7 required research practices based on AHRQ’s recommendations, compiled under 3 domains: (A) data interpretation (interpreting data as hospitalization records rather than unique patients); (B) research design (avoiding use in performing state-, hospital-, and physician-level assessments where inappropriate; not using non-specific administrative secondary diagnosis codes to study in-hospital events), and (C) data analysis (accounting for complex survey design of the NIS and changes in data structure over time). Results Of 120 published studies, 85% (n=102) did not adhere to ≥1 required practices and 62% (n=74) did not adhere to ≥2 required practices. An estimated 925 (95% CI 852–998) and 696 (95% CI 596–796) NIS publications had violations of ≥1 and ≥2 required practices, respectively. A total of 79 sampled studies, representing 68.3% (95% CI 59.3–77.3) of the 1082 NIS studies, did not account for the effects of sampling error, clustering, and stratification; 62 (54.4%, 95% CI 44.7–64.0) extrapolated non-specific secondary diagnoses to infer in-hospital events; 45 (40.4%, 95% CI 30.9–50.0) miscategorized hospitalizations as individual patients; 10 (7.1%, 95% CI 2.1–12.1) performed state-level analyses; and 3 (2.9%, 95% CI 0.0–6.2) reported physician-level volume estimates. Of 27 studies (weighted: 218 studies, 95% CI 134–303) spanning periods of major changes in the data structure of the NIS, 21 (79.7%, 95% CI 62.5–97.0) did not account for the changes. Among the 24 studies published in journals with an impact factor ≥10, 16 (67%) and 9 (38%) did not adhere to ≥1 and ≥2 practices, respectively. Conclusions and Relevance In this study of 120 recent publications that used data from the NIS, the majority did not adhere to required practices. Further research is needed to identify strategies to improve the quality of research using the NIS and assess whether there are similar problems with use of other publicly available data sets.

IMPORTANCE Acute myocardial infarction (AMI) complicated by cardiogenic shock is associated with substantial morbidity and mortality. Although intravascular microaxial left ventricular assist devices (LVADs) provide greater hemodynamic support as compared with intra-aortic balloon pumps (IABPs), little is known about clinical outcomes associated with intravascular microaxial LVAD use in clinical practice. OBJECTIVE To examine outcomes among patients undergoing percutaneous coronary intervention (PCI) for AMI complicated by cardiogenic shock treated with mechanical circulatory support (MCS) devices. DESIGN, SETTING, AND PARTICIPANTS A propensity-matched registry-based retrospective cohort study of patients with AMI complicated by cardiogenic shock undergoing PCI between October 1, 2015, and December 31, 2017, who were included in data from hospitals participating in the CathPCI and the Chest Pain-MI registries, both part of the American College of Cardiology's National Cardiovascular Data Registry. Patients receiving an intravascular microaxial LVAD were matched with those receiving IABP on demographics, clinical history, presentation, infarct location, coronary anatomy, and clinical laboratory data, with final follow-up through December 31, 2017. EXPOSURES Hemodynamic support, categorized as intravascular microaxial LVAD use only, IABP only, other (such as use of a percutaneous extracorporeal ventricular assist system, extracorporeal membrane oxygenation, or a combination of MCS device use), or medical therapy only. MAIN OUTCOMES AND MEASURES The primary outcomes were in-hospital mortality and in-hospital major bleeding. RESULTS Among 28 304 patients undergoing PCI for AMI complicated by cardiogenic shock, the mean (SD) age was 65.0 (12.6) years, 67.0% were men, 81.3% had an ST-elevation myocardial infarction, and 43.3% had cardiac arrest. Over the study period among patients with AMI, an intravascular microaxial LVAD was used in 6.2% of patients, and IABP was used in 29.9%. Among 1680 propensity-matched pairs, there was a significantly higher risk of in-hospital death associated with use of an intravascular microaxial LVAD (45.0%) vs with an IABP (34.1% [absolute risk difference, 10.9 percentage points {95% CI, 7.6-14.2}; P < .001) and also higher risk of in-hospital major bleeding (intravascular microaxial LVAD [31.3%] vs IABP [16.0%]; absolute risk difference, 15.4 percentage points [95% CI, 12.5-18.2]; P < .001). These associations were consistent regardless of whether patients received a device before or after initiation of PCI. CONCLUSIONS AND RELEVANCE Among patients undergoing PCI for AMI complicated by cardiogenic shock from 2015 to 2017, use of an intravascular microaxial LVAD compared with IABP was associated with higher adjusted risk of in-hospital death and major bleeding complications, although study interpretation is limited by the observational design. Further research may be needed to understand optimal device choice for these patients.

IMPORTANCERecent reports from communities severely affected by the coronavirus disease 2019 (COVID-19) pandemic found lower rates of sustained return of spontaneous circulation (ROSC) for out-of-hospital cardiac arrest (OHCA). Whether the pandemic has affected OHCA outcomes more broadly is unknown.OBJECTIVE To assess the association between the COVID-19 pandemic and OHCA outcomes, including in areas with low and moderate COVID-19 disease burden. DESIGN, SETTING, AND PARTICIPANTS This study used a large US registry of OHCAs to compare outcomes during the pandemic period of March 16 through April 30, 2020, with those from March 16 through April 30, 2019. Cases were geocoded to US counties, and the COVID-19 mortality rate in each county was categorized as very low (0-25 per million residents), low (26-100 per million residents), moderate (101-250 per million residents), high (251-500 per million residents), or very high (>500 per million residents). As additional controls, the study compared OHCA outcomes during the prepandemic period (January through February) and peripandemic period (March 1 through 15). EXPOSURE The COVID-19 pandemic. MAIN OUTCOMES AND MEASURES Sustained ROSC (Ն20 minutes), survival to discharge, and OHCA incidence. RESULTS A total of 19 303 OHCAs occurred from March 16 through April 30 in both years, with 9863 cases in 2020 (mean [SD] age, 62.6 [19.3] years; 6040 men [61.3%]) and 9440 in 2019 (mean [SD] age, 62.2 [19.2] years; 5922 men [62.7%]). During the pandemic, rates of sustained ROSC were lower than in 2019 (23.0% vs 29.8%; adjusted rate ratio, 0.82 [95% CI, 0.78-0.87]; P < .001). Sustained ROSC rates were lower by between 21% (286 of 1429 [20.0%] in 2020 vs 305 of 1130 [27.0%] in 2019; adjusted RR, 0.79 [95% CI, 0.65-0.97]) and 33% (149 of 863 [17.3%] in 2020 vs 192 of 667 [28.8%] in 2019; adjusted RR, 0.67 [95% CI, 0.56-0.80]) in communities with high or very high COVID-19 mortality, respectively; however, rates of sustained ROSC were also lower by 11% (583 of 2317 [25.2%] in 2020 vs 740 of 2549 [29.0%] in 2019; adjusted RR, 0.89 [95% CI, 0.81-0.98]) to 15% (889 of 3495 [25.4%] in 2020 vs 1109 of 3532 [31.4%] in 2019; adjusted RR, 0.85 [95% CI,) in communities with very low and low COVID-19 mortality. Among emergency medical services agencies with complete data on hospital survival (7085 total patients), survival to discharge was lower during the pandemic compared with 2019 (6.6% vs 9.8%; adjusted RR, 0.83 [95% CI, 0.69-1.00]; P = .048), primarily in communities with moderate to very high COVID-19 mortality (interaction P = .049). Incidence of OHCA was higher than in 2019, but the increase was largely observed in communities with high COVID-19 mortality (adjusted mean difference, 38.6 [95% CI, 37.1-40.1] per million residents) and very high COVID-19 mortality (adjusted mean difference, 28.7 [95% CI,] per million residents). In contrast, there was no difference in rates of sustained ROSC or survival to discharge during the prepandemic and peripandemic periods in 2020 vs 2019.CONCLUSIONS A...

Background Although previous studies have shown marked variation in out-of-hospital cardiac arrest survival across U.S. regions, factors underlying this survival variation remain incompletely explained. Methods and Results Using data from the Cardiac Arrest Registry to Enhance Survival, we identified 96,662 adult patients with out-of-hospital cardiac in 132 U.S. counties. We used hierarchical regression models to examine county-level variation in rates of survival and survival with functional recovery (defined as Cerebral Performance Category score of 1 or 2) and examined the contribution of demographics, cardiac arrest characteristics, bystander cardiopulmonary resuscitation (CPR), automated external defibrillator (AED) use, and county-level socio-demographic factors in survival variation across counties. A total of 9317 (9.6%) patients survived to discharge, and 7176 (7.4%) achieved functional recovery. At a county-level, there was marked variation in rates of survival to discharge (range: 3.4%-22.0%, median odds ratio [MOR] 1.40, 95% CI 1.32-1.46) and survival with functional recovery (range: 0.8%-21.0%, MOR 1.53, 95% CI 1.43-1.62). County-level rates of bystander CPR and AED use were positively correlated with both outcomes (P<0.0001 for all). Patient demographic and cardiac arrest characteristics explained 4.8% and 27.7% of the county-level variation in survival, respectively. Additional adjustment of bystander CPR and AED explained 41% of the survival variation, and this increased to 50.4% after adjustment of county-level socio-demographic factors. Similar findings were noted in analyses of survival with functional recovery. Conclusions Although out-of-hospital cardiac arrest survival varies significantly across U.S. counties, a substantial proportion of the variation is due to differences in bystander response across communities.

BACKGROUND Despite ongoing efforts to improve the quality of pediatric resuscitation, it remains unknown whether survival in children with in-hospital cardiac arrest has improved. METHODS & RESULTS Between 2000 and 2009, we identified children (<18 years) with an in-hospital cardiac arrest at hospitals with ≥ 3 years of participation and ≥ 5 cases annually within the national Get With The Guidelines-Resuscitation registry. Multivariable logistic regression was used to examine temporal trends in survival to discharge. We also explored whether trends in survival were due to improvement in acute resuscitation or post-resuscitation care and examined trends in neurological disability among survivors. Among 1031 children at 12 hospitals, the initial cardiac arrest rhythm was asystole and pulseless electrical activity in 874 children (84.8%) and ventricular fibrillation and pulseless ventricular tachycardia in 157 children (15.2%), with an increase in cardiac arrests due to asystole and pulseless electrical activity over time (P for trend <0.001). Risk-adjusted rates of survival to discharge increased from 14.3% in 2000 to 43.4% in 2009 (adjusted rate ratio per 1-year 1.08; 95% CI [1.01,1.16]; P for trend 0.02). Improvement in survival was largely driven by an improvement in acute resuscitation survival (risk adjusted rates: 42.9% in 2000, 81.2% in 2009; adjusted rate ratio per 1-year: 1.04; 95% CI [1.01,1.08]; P for trend 0.006). Moreover, survival trends were not accompanied by higher rates of neurological disability among survivors over time (unadjusted P for trend 0.32), suggesting an overall increase in the number of survivors without neurological disability over time. CONCLUSION Rates of survival to hospital discharge in children with in-hospital cardiac arrests have improved over the past decade without higher rates of neurological disability among survivors.

In STEMI patients undergoing primary PCI, the radial approach is associated with favorable outcomes and should be the preferred approach for experienced radial operators.

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